19977APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idenrlfkrtlon
ButW ing Address '
z s� CV—k 2 VL,i [S 3`1 11 0 T119977
PERMIT W.
era me.
Fay—ut-c
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
BUfI.DING-EL=CALML BINGMEC�
APPLICA11UNhUbMillAi,
Contano/a Name: Lk. No:
"HANKAL CATEGORY
CONTROL Y
ArcM1Bt/Englver. Lk. o:
CITY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: (eye Q I S 341„} � F
PERMTIISSUANCE
jr;7j 1:1 El ❑
I�
LICENSED CONTRACTORS DECIARATION '
Ihertby affirm Wtlamlke wduMerpr Wb of Chaptn9(�c
Ingwlth Section7DOD)of Dtv m3ofthe BuMrc and Pmfesi Cydq dmy
Ibeme la In full f....d effect
LI¢nae Clan Lk.. '
Date Confraet.,
ARCHITECTS DECLARATION
I urdieatand my plan shall be used u public records
Lteanoad Profesbvl
OWNER-BUILDER DECIARATION
I hereby.(Drm [Fat I am hemp tmm the Cordradors Llreve I�wla the
tollowbg rtasm. Lz1`0 7015, Bushes a rd Prof. to os Cad a.. Any dtym
muntywhkb require. panic tomnmud, alter, Improve, demolish, or repair
any atruceum prior to lb buarcq.Im rqulm the.ppliant for sort, permk to
file a signed statement that he b Versed purtwant to the pmviWv of the
Cantrmdoesl, er law(Chaper9(mmmendngwKh Sedlon70DD)of Dld-
utno3 ofthe Bud wl eaProtessloro Code) orthe heirxe
empt therefromad
tk bub for the alkged exemption. Any vidatbn of Section 70715 by any
applicator for a pemdt subjectsthe applicant to a elvll penalty of not moa than
flue hundred dollars (x500).
e n owrcr l the property, or he employee wkh wage r there dab
mk5m7OK Bu1dotheworlrandthesCru . is ren WerdedoroffcrMf
dk( 7plywslrowa ci ofp" Cade The Contaci m hemr law
dos cwt apply to an owner ofproperty who Wilde arlmpvvetherton,and
whodmact, work hhreen mthwghffered mwm employee,pesoWedthatouch
improvement)aremitteededoro.fe.pleconthe oweventhe WlWlnase
improvemed badd whhW oneynro(completW .,the ownerbullderwW Tuve
Xt d.en of pre ing that he did rwt bund or Improve (or purpose of k.),
161 L e owner of the Property, am exclusr oly mntre,ung with Boerw.d
Rare to mmtrun the projeci (Sec 7DK Buen® and I#ofesbv Cade,
The Coruaeur'9 License Lw does not apply to an owner a property who
Wilde or Improves [Ferro., and sob mmraeta fee aueh p�ojeds wah a
ry➢�acteWll¢nned Pasoan[to tFeCmtraed Lloenl La W.
U I am e.emp under Sec B 4 P C for thin renin
Owner d 13H40
WORKMAN COMP.o,,tj IO RATION
❑I aereby affirm that I eref o Ins o c rent m .eR-Wurt, (S.
mrtlilateofWarken'CompevNlonlvunn¢a. ¢rilfkd mpytherto((Sec.
Polis LbCJ
4
APPLIANC6RESmENfUL
BDEiRIPUON
Ou CILLI/
hJ F' �/�
PANELS
2014()0() AMPS
OVER 10DOAMPS
SQ. FT. FLOOR AREA
IN
R
$/SQ. FT.
SIGNS ELECTRK'AL
=TALCIRCLT/MlSC
TFMP.MEfER ORF'(71-E '
POWER DEVICES
DATE
SWENh9NG POOL ELECTRIC
OUTLYTSSWITCI�SFLXTURFS
VALUATION
Q DO
��O Q a
NEW RESIDENTIAL EI= SQFr.
STORIES
ITT CONSMUCTIO\
'
V—+ j
TOTAL
QTY. PLUMBING PERMIT FEE
OCC.GROUP
RES. UNITS
,
PEtk(IT ISSUANCE
ALTER-DRAINk VENT- WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FIDWPROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y_ N_
RECERTI
FO(TURES PER .TRAP
Sai00l, TAX Y_ N
RECFIT T
GAS FA. S-YSI.FA7.11NG40UILETS
PARK FEF- Y - N
GAS FA. SYSTEM -OVER 4(EA)
Cum y
BUILDRWFUrING DIVISION
BDILDINC DI VISION FEES
CerWkd copy hereby nrmbhed.
CertWed ropy b Wed with the eity, lvp tion dtv m.
CERTIFICATE OF OKENIMON FROM WORKERS
COMPENSATION INSURANCESEv+ER-sAND.nRY
(Thiolectionneed not becompleted Ifthe pemit Isferro ehundrdm
edoe
(siOO) Of Tea)
I ¢rtlfy, that W the Nrl.rm.n¢ of the work farwMeh lin. Pemdt b blued,
I ahAl net employ any penin In any nanner an u to become object to the
Workcri Compsvdlon laws of CalOoab. Date
Apipheart
NOT[CE]O APPLICANT mking,m
shmldmisob}ctoheWoe;CompevtnpmdWmofthe Labor
deemedrevoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there ba mebucttm kodingageney for the perform
permitec. 309'7
ance of the work for which this permit b issued (S, Clv. C.)
lender. Name
Lenders Add .
1mdltythatIlovemadthioappl tbnaM"ai thmtheabove Wforevtim
ower[. IagreetocumplywhhaB dty.ndmuntyordinanmand Yatelawe
neloting to W lWing mvtmnlm, and heneby authorlo a representative of thio
cilytoenter upon the above-mentioned property for inspection purpose
(We) agree to aavq bdemN(y an d keep bend. the City of Cu Penton
.gaWt B�abbWtles, ju/cdoCggmnds, mtl.ard expense w Jch may to aanyQaye,rue
r/J /
GREASE/N'DUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recd t#
GREASE TILAP -
STDxM En,�,
WATFRHEATERW/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Recel t#
WA77R SYSTEM/TREATING
NEW RESIDENTIAL PIMB. SQFI.
TOTAL-
OTALdenied
BUILDING
SEISMIF, FEE
TOTAL,
FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID.
ALTFRORADDTOMECFL
Date R2CC1 [#
AIR HANDLING UNIT(TO 10,ODO CFM)
SUBTOTAL:
wIR HANDUNc unTr rovFx l4000cehn
CONSTRUCTION TAX
Signature of Applicant, @mrtnetor p, IDate
FA2 RDOUS MATERIAL9 DISC SURE
WWtheappBod or future building oavpant,t.,e.e handle hauNoui
material a. defined by the Cupertino Municipal Code, Chapter 9.12, and the
I[eahhand Safety Code Stlm25532(p)2
IYes M No
Rl the applied or future Wilding oecopant use equipment or deAe,a
whkh emit ha rdeus air mnanwunte as deflned by the Bay Arca Alr
Qo IFy Management Dbfrtet2
4Yea ❑ No
u ertad tM1eh rdousrvterlabrequlmmenbunder Chapterb95of
the CalOomla Health k Safety Code, Stbv 5505, S Sand 25534.1
underatard that if the building don not eume.fly have. tenant, that It is my
resporo(bRity to notify the o¢vpant of the requlremcm. whkh .vet be reed
prlmtotauanreofa Ccrtl(kateof Oerupe,cy.
E7 1.15T HOOD(W/DLc-D
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTL
Date Rttei t#
HFATING UNIT (OVER IDO,OOD BTU)
it TOTAL:
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
L[ •`
rn :/�,-,SLt
res,` l•
luf�� rt1n 1^n
V * ` T
ISSUED BY:: _
BOILER -COMP OHP OR 1W,IXA RTL
BOILER COMP (OVER IOD,OOD BTL
NEWRESIDFNTIALMECI SQFI
Owner w authorise a gent Date
TOTAL:
OFFICE COPY